Provider Demographics
NPI:1942804182
Name:JACOB, SUBY (RPH)
Entity Type:Individual
Prefix:MRS
First Name:SUBY
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BOONTON TPKE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07035-1761
Mailing Address - Country:US
Mailing Address - Phone:973-628-2002
Mailing Address - Fax:
Practice Address - Street 1:15 BOONTON TPKE
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:NJ
Practice Address - Zip Code:07035-1761
Practice Address - Country:US
Practice Address - Phone:973-628-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03199600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist